Preventing waste: A ritual analysis of candidate selection for kidney transplantation

To examine how sociocultural factors influence transplant professionals' decisions about placing patients on the national transplant waiting list, I observed discussions at 15 candidate selection meetings at one urban transplant center. Transplant professionals are uncertain about whether to place marginally suitable candidates on the waiting list. Uncertainty derives from competing cultural and ethical imperatives: ensuring equal access to transplantation and efficient use of scarce kidneys to prevent waste. Patients with psychosocial contraindications to transplantation, e.g. noncompliance, drug use, ambivalence, present this ethical challenge most sharply to transplant professionals. Transplant professionals deal with this by either: routinely discussing patients' potential for noncompliance or delaying noncompliant patients' access to the waiting list through a probationary contract. Through ritual analysis of transplant candidate selection meetings, I explain why these approaches are pragmatic in that they help the transplant team resolve conflict between their competing values and thus resolve their uncertainty about wait-listing marginal patients for transplantation.